The personal prophylaxis of venereal diseases[332] has made great progress with the increasing scientific knowledge of the causes and modes of infection of these diseases. We know now precisely where and how we can lay down personal rules which give us at least a fairly secure guarantee that in an individual case venereal infection will not occur. Various points of view must then be taken into consideration, the combined influence of which will alone promise a successful result. No one single measure will suffice to gain this end.
Above all, in this department of the prophylaxis of venereal diseases, experienced physicians, alike of earlier and more recent times, will unanimously agree in this proposition, that the principal preliminary means for the avoidance of venereal infection, means which it is absolutely essential to employ in every instance, consist of perfect cleanliness on both sides. He who insists on the most scrupulous cleanliness of body, clothing, and underclothing, will be sure to get rid immediately of any uncleanliness acquired in sexual intercourse. Cleanliness and health are often (not always) identical. In any case, the greatest mistrust should be felt as regards a person evidently unclean, with a neglected exterior, for this is always a sign that such a person is not particular as regards choice in matters of sexual intercourse. “Germany, get into your bath!” Heinrich Laube once exclaimed. This would be a good device to adopt in the campaign against venereal diseases. Every uncleanliness is an irritant; it impairs the intactness of the skin; and especially is this true of any uncleanliness of the genital organs, and above all of the male genital organs, where, under the foreskin, the “smegma” (the sebaceous secretion of the preputial glands) often undergoes decomposition, and gives rise to an inflammation, the so-called balanitis, which greatly favours the probability of infection.[333]
If the foreskin has been removed by circumcision, this secretion entirely ceases, and the mucous membrane covering the glans penis is transformed into a thick skin, which is much less readily affected by the causes of infection. There is no doubt that circumcision is to a certain extent a protective measure against syphilitic infection, whilst it does not in any way protect against gonorrhœa. Neustätter has recently collected some very remarkable facts relating to this question.[334]
Breitenstein has contrasted 15,000 indigenous circumcised soldiers with 18,000 uncircumcised European soldiers of the army of the Dutch Indies, living under similar local and hygienic conditions. Thus, in the year 1895 there were infected with venereal diseases, of the circumcised 16 %, of the uncircumcised 41 %. As regards infections with syphilis, of the circumcised 0·8 % were infected; of the uncircumcised, on the other hand, 4·1 %—that is, five times as many. Similar observations were made by the celebrated English syphilologist Jonathan Hutchinson, one of the most ardent advocates of the general introduction of circumcision as a protective measure against venereal, and above all against syphilitic, infection. Moreover, with regard to the observations made in Java, the difference did not depend upon race, because similar differences have been observed as regards comparative immunity from infection in respect of circumcised Christians, circumcised on account of phimosis and other troubles, whose number is by no means insignificant.
Since, however, it is unlikely that circumcision will come into general use in Europe as a prophylactic measure, it only remains to recommend that, as a fundamental procedure, the greatest possible care should be employed in the daily and delicate cleansing of the preputial sac. By this means inflammation and laceration of these parts will be most effectually prevented, and even without circumcision a certain resisting power will be induced. For washing this region, lukewarm water which has been boiled and cooled may best be employed; then dry the part carefully, so as not to rub off the skin. In the case of women, frequent washings of the external genital organs, and vaginal douches, are also of great importance in regard to the prevention of venereal infection. Before and after the sexual act, these measures are of especial value, because often by simple mechanical means, infective material already deposited may be carried away. The same purpose is subserved by urination, a procedure certainly adapted for washing out gonorrhœal pus which has found its way into the urethra, before the gonococci have had time to establish themselves in the mucous membrane. I know a number of patients who use no other means of protection in sexual intercourse beyond the observation of extreme cleanliness, by washing and douching, in both sexes, before and after sexual intercourse, and by passing water immediately after intercourse, and thus have remained free from infection; but who promptly became infected as soon as they discontinued these simple measures.
For this reason, these measures, where possible with the assistance of soap, which certainly exercises some antiseptic influence, cannot be too warmly recommended, although they naturally do not offer any absolute security. They have, however, the advantage that, in the first place, they can always be employed, even when the true protective measures of which we speak below are not available, and that, in the second place, they can always be used in addition to these. It sounds, perhaps, somewhat absurd, and yet it is true, to say that washing and urination are the first and most important protective measures against sexual infection.
The second point, which must also be considered important in this connexion, is the exercise of self-command before and during the sexual act, as far as this is possible in view of the nature of sexual excitement, which always lessens the personal responsibility, and overcomes reason and understanding. Yet no one should have sexual intercourse when in a state of alcoholic intoxication, in which self-control is completely lost; as we have shown in an earlier passage ([pp. 292]-[296]), there are several reasons why intercourse is apt to be disastrous to a drunken man. Moreover, love prefers the dark, but precaution prefers the sunlight. Before having intercourse with a woman previously unknown to him, a man should inspect her in clear daylight, with a view to her state of health. Suspicious spots on the skin, especially on the forehead and on the trunk; white areas on the lips, the tongue, the throat, and the back of the neck; visible glandular swellings; a marked discharge from the genital organs; ulcerated areas in this region, etc., are of an extremely suspicious nature, and should cause abstinence from intercourse. French physicians go so far as to recommend examination of the inguinal and cervical glands under the harmless form of pretended caresses; but persons without medical education would seldom be sufficiently skilled to be able to detect glandular swellings unless these were unusually well developed. Especially enlargement of the cervical glands—this “pulse of syphilis,” as Alfred Fournier terms it—is a comparatively certain indication of syphilis.
It is dangerous also in many cases to repeat the sexual act several times in brief succession, because old experience has taught us that infective material may first make its appearance at the second or third act of coitus, and thus infect then only. This affords an explanation also of a fact often observed—that in intercourse with an infected woman on the part of two healthy men, with but a brief interval between the acts, the one who had intercourse first often remains healthy, whilst the second is infected.
I pass on to consider the special protective measures which have long been recommended for the prophylaxis of venereal infection.
1. The Condom.—This is the oldest and even to-day beyond question the best and most trustworthy artificial protective measure. Employed long ago in the days of antiquity, it was in the sixteenth century once more recommended by the Italian physician Fallopius, and therefore is not the invention of a physician “Conton,” after whom it is said to have been named (perhaps the name is connected with that of the French town “Condom”). Hans Ferdy (A. Meyerhof) suggests that the word is derived from “condus”—that is, one who preserves or protects—and that the article should properly be called “condus” instead of “condom.”[335]